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Application
Online Application
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Membership
Knighthood
Diploma
List all educational institutions attended since Secondary or High School, including professional schools and certificates, diplomas and degrees obtained.
State the name of the state or country where you are licensed to practice your profession and where you expect to use the CME certification from this college
State and/or Country
Year Issued
Are you in good standing with the licensing board?
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Will you be able to use our certification in your state or country?
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What is your specialization?
How many years experience do you have in your specialty?
State any postgraduate experience or degree obtained.
Our journal is mandatory for members. Are you willing to subscribe to the journal and pay annual subscriptions?
Yes
No
Do you understand that our Memberships, Knightships and Diplomas are available in all of the listed specializations, and these are professional Diplomas and Knightships not designed as transferrable credit for collegiate level work?
Yes
No
With the completed application, I am enclosing the following required document (for initial processing) with my application
Copy of professional degree, certificates or diploma
Copy of license to practice medicine where the certificate (of this college) is to be used
Item #16 above
A detailed curriculum vitae or bio data
Passport sized photo with name and signature on back
Non-refundable application fee of $300.00 for determination of eligibility. Payment must be made in USA dollars, traveler’s check, money orders, and bank checks are all acceptable and made payable to: “The Royal College of Physicians and Surgeons USA.”
RCPSUS Membership fee is $2800.00 USD plus $300 application fee. The $2800.00 USD fee is refundable if the application is not approved by the Committee.
Research and Publications (use separate paper if necessary)
List all research works that you have conducted or participated (type, purpose, subject matter, descriptions, institution where it was conducted, supervisor and whether it was published:
List the publishers and dates of books, monographs, or pamphlets published
List the titles of articles (Journals and dates) published or unpublished:
List recent seminars, medical meetings, symposiums, and conferences attended:
List awards and honors received:
Have you ever applied to this organization for admission into any of it’s programs at any time?
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Languages spoken or written:
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Specialty List available on website
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I certify that I Voluntarily enroll and willingly support the concept of Continuing Education Programs for doctors. I am licensed in the country where I intend to use the /Memberships, Fellowships, and Diplomas certificate (s) that I am applying for. I am enclosing a $300 non-refundable application fee OR the complete tuition fee. I understand that no action will be taken on my application without payment of fee and submitting all the required credentials. I authorize full investigation of my application. My signature below is the authorization to anyone to release any information you may request on me. I agree that my competency in clinical skills and professional qualifications will be evaluated and the Royal College may make inquiry or release information about me concerning this matter. I agree to indemnify, release and hold harmless the Royal College of Physicians and Surgeons and its Agents from any liabilities or torts by reason of their acts or omissions in connection with this application. I agree to abide by the decision of the Royal College or its agents. We agree to submit to arbitration under the American Arbitration Association for any controversy, claims, torts and tort nuisance and other related violations. We are to submit the above controversies to above arbitrators in Detroit, Michigan, USA, and a judgment of the competent court may enter such award of the arbitrators. I agree to function within the limits of my competency and I guarantee and warrant that the Royal College of Physicians and Surgeons (and its agents) assume no responsibility for any of my activities or actions. It is understood by me that any falsification of records, misrepresentation of material facts, dishonesty, forgery, and unethical practices will automatically render any Memberships, Fellowships or Diplomas certifications awarded to me NULL and Void. Under penalty of perjury, I guarantee and warrant that all information provided on all pages of this application are true and correct. I am legally bound by the foregoing as attested to here with my signature below. The Royal College of Physicians and Surgeons admits professionals to its organizations of any race, color, national origin, sex, age, handicap, or religious preference in its education programs, activities, and employment as required by the Civil Rights Act of 1964 and Amendments including Title IX of the Educational Amendments of 1972.
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